Screening

							                    AME 10.15.07 to 10.19.07 Depression: Screening
                                    Author: Eric Warm M.D.


                                                                                        Attending Version
Competencies: Medical Knowledge, Patient Care

Learning Objectives: After reading this information you should be able to properly screen and diagnose
depression in your patients

Key Points

    Major depression is one of the most common diagnoses seen in our practice, and is encountered by
     all physicians in all specialties

    Two good screening questions that may lead to further investigation are:
              Over the past two months, have you been bothered by:
                  Little interest or pleasure in doing things?
                  Feeling down, depressed and hopeless?

    If the patient answers "yes" to either one of the above questions, consider using a quantitative
     questionnaire (see the PHQ-9 below) to further assess whether the patient has sufficient
     symptoms to warrant a diagnosis of clinical major depression and a full clinical interview



Presentations for depression include:

      Multiple (>5/year) medical visits                       Weight gain or loss
      Multiple unexplained symptoms                           Sleep disturbance
      Work or relationship dysfunction                        Fatigue
      Changes in interpersonal relationships                  Dementia
      Dampened affect                                         Irritable bowel syndrome
      Poor behavioral follow-through with                     Volunteered complaints of stress or mood
       activities of daily living or prior                      disturbance
       treatment recommendations

Risk Factors for major depression include:

      Family or personal history of major                     Domestic abuse/violence
       depression and/or substance abuse                       Traumatic events (car accident)
      Recent loss                                             Major life changes (job change)
      Chronic medical illness                                 Emotional and behavioral reactions to
      Dysthymia                                                these social stressors can include
      Stressful life events that include loss                  symptoms of major depression
       (death of a loved one, divorce)
Major depression is also seen in elderly patients with comorbid illnesses, such as cerebrovascular accident
(CVA), cancer, dementia or disabilities.

Patients with a history of mood disorders are at increased risk for postpartum depression. Several
depressive conditions may follow childbirth. "Postpartum Blues" affects 50%-85% of mothers in the first
two weeks after delivery. It is characterized by mood lability, tearfulness, anxiety and sleep disturbance
but usually does not result in functional impairment. No specific treatment is required. If the patient
remains significantly depressed 3-4 weeks following delivery, it should be considered serious and treated
including eliminating medical causes of depressive symptoms such as postpartum thyroid disorders or
anemia. The first two to three months postpartum is the period of greatest risk for the development of
major depression.

The close relationship of mind and body results in the presentation of medical illness with major
depression in various forms:

      Medical illness may be a biological cause (e.g., thyroid disorder, stroke).
      Medical illness or patient's perception of his or her clinical condition and health related quality of
       life may trigger a psychological reaction to prognosis, pain or disability (e.g., in a patient with
       cancer).
      Medical illness may exist coincidentally in a patient with primary mood or anxiety disorder.

Diagnose and Characterize Major Depression with Clinical Interview

Depressed mood or anhedonia (diminished interest or pleasure in activities) is necessary to diagnose
major depression. If depression is suspected on the basis of risk factors of common presentations,
consider using a standardized instrument to document depressive symptoms. More importantly, document
baseline symptoms and severity to assist in evaluating future progress. Useful initial questions include:

               Over the past two months, have you been bothered by:

                     Little interest or pleasure in doing things?
                     Feeling down, depressed and hopeless?

If the patient answers "yes" to either one of the above questions, consider using a quantitative
questionnaire (see the PHQ-9 below) to further assess whether the patient has sufficient symptoms to
warrant a diagnosis of clinical major depression and a full clinical interview.

The use of a mnemonic may likewise be helpful for remembering the symptoms of major depression and
dysthymia. SIGECAPS or SIG + Energy + CAPSules is easily remembered and can be used in the clinical
interview. It was developed by Dr. Carey Gross of Massachusetts General Hospital and stands for:

Sleep disorder (increased or decreased)                   Concentration deficit
Interest deficit (anhedonia)                              Appetite disorder (increased or decreased)
Guilt (worthlessness, hopelessness, regret)               Psychomotor retardation or agitation
Energy deficit                                            Suicidality
Determine history of present illness including:

      Onset may be gradual over months or years or may be abrupt.
      Severity of symptoms and degree of functional impairment:

People diagnosed with major depression have a heterogeneous course from self-limiting to life-
threatening. Predictors of poor outcome include severity at initial assessment, lack of reduction of social
difficulties at follow-up and low educational level. Categorize severity of symptoms and degree of
functional impairment as follows:

      Mild: few, if any, symptoms in excess of those required to make the diagnosis and only minor
       impairment in occupational and/or social functioning
      Moderate: symptoms or functional impairment between mild and severe
      Severe: several symptoms in excess of those necessary to make the diagnosis and marked
       interference with occupational and/or social functioning

Ask about the umber and severity of previous episodes, treatment responses and suicide attempts.

Ask about concurrent psychiatric conditions. Obtaining a past psychiatric history is important in terms of
understanding prognosis and risk factors. For example, knowledge of past episodes of major depression,
past co-occurring mental/behavioral health conditions, and past self-harm attempts is important for
establishing risk and need to involve other mental health professionals.

Psychosocial stressors (significant loss, conflict, financial difficulties, life change, abuse).

Pertinent medical history that may complicate treatment includes prostatism, cardiac conduction
abnormalities, and impaired hepatic function. A past medical history and brief review of systems is
generally sufficient to rule out medical disorders causing major depression.

Perform a focused physical examination and laboratory testing as indicated by the review of systems. The
benefit of screening laboratory tests, including thyroid tests, to evaluate major depression has not been
established.

Reliance on laboratory tests should be greater if:

      The medical review of systems detects symptoms that are rarely encountered in mood or anxiety
       disorders
      The patient is older
      The first major depressive episode occurs after the age of 40
      The depression does not respond fully to routine treatment
Determine past history of substance abuse.

      Medications and withdrawal from medications such as reserpine, steroids, alpha-methyldopa,
       propranolol and hormonal therapy may be associated with major depression.
      Withdrawal from alcohol, cocaine, sedatives, anxiolytics, hypnotics and amphetamines may be
       associated with depression.
      Idiosyncratic reactions to other medications can occur and if possible, a medication should be
       stopped or changed if depression develops after beginning its use. If symptoms persist after
       stopping or changing medication, reevaluate for a primary mood or anxiety disorder.

Five or More Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision
(DSM-IV TR) Criteria Present?

A. Five or more of the following symptoms have been present and documented during the same 2-week
period and represent a change from previous functioning; at least one of the symptoms is either (1)
depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-congruent
delusions or hallucinations.

   1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g.,
      feels sad or empty) or observation made by others (e.g., appears tearful).
   2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly
      every day (as indicated by either subjective account or observation made by others)
   3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body
      weight in a month), or decrease or increase in appetite nearly every day
   4. insomnia or hypersomnia nearly every day
   5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective
      feelings of restlessness or being slowed down)
   6. fatigue or loss of energy nearly every day
   7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly
      every day (not merely self-reproach or guilt about being sick)
   8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective
      account or as observed by others)
   9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific
      plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms do not meet criteria for a mixed episode.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other D. D.
D. important areas of functioning.
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g., hypothyroidism).
F. The symptoms are not better accounted for by bereavement ( i.e., after the loss of a loved one, the
symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid
preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation).
G. The assessment of major depressive disorders should include the DSM-IV TR numerical rating of the
disorder with all 5 digits, thus including a severity rating.
The Patient Health Questionnaire (PHQ-9)

The Patient Health Questionnaire contains a brief, 9-item, patient self-report depression assessment
specifically developed for use in primary care (PHQ-9). The PHQ-9 has demonstrated usefulness as an
assessment tool for the diagnosis of depression in primary care with acceptable reliability, validity,
sensitivity, and specificity. The nine items of the PHQ-9 come directly from the nine DSM-IV signs and
symptoms of major depression. Patients should not be diagnosed solely on the basis of a PHQ-9 score.
The clinician should corroborate the score with clinical determination that a significant depressive
syndrome is present. After making a provisional diagnosis with the PHQ-9, there are additional clinical
considerations that may affect decisions about management and treatment.

The primary objective is to use a standardized instrument that will quantify and document future
progress, including response and remission rates.

Real World Use and Expectations of the PHQ-9

The participants in the Chronic Care Model pilot who are studying depression ( we are studying diabetes)
have set the following goals for themselves:

> 40% of the Clinically Significant Depression (CSD) patients with 50% reduction in PHQ
> 70% of the CSD patients with documented PHQ reassessment between 4-8 weeks of last New Episode
PHQ
> 80% of CSD patients on an antidepressant &/or in psychotherapy within one month of last New Episode
PHQ


We now have the PHQ-9 available in the clinic – you can find them in the handout section of the
precepting room (near the top).


                                             QUESTIONS

Today we will not have multiple choice questions. The exercise will be the following:

Take five minutes to review, fill out and score the PHQ-9 on the next page. All answers on the PHQ-9
will be kept confidential – you don’t have to share them with anyone.

After completing the PHQ-9 please answer the following questions with the group

1. What did you think of the PHQ-9?
2. What do you think your patients will think?
3. What barriers do you foresee with using the PHQ-9 with your patients?
4. How will you overcome those barriers?
5. Have any of you used this tool? Please share your experience with the group.
                      PATIENT HEALTH QUESTIONNAIRE PHQ-9
  NAME ______________________________ PROVIDER _____________ DATE ________CHART
                                     # _________

        Over the last 2 weeks, how often have you been bothered by any of the following problems?
                                                                                          (2)
                                                              (0)          (1)                               (3)
                                                                                      More Than
                                                            Not At       Several                        Nearly
                                                                                       Half the
                                                             All          Days                         Every Day
                                                                                        Days
 1. Feeling down, depressed, or hopeless?

 2. Little interest or pleasure in doing things?
 3. Trouble falling or staying asleep, or sleeping too
    much?
 4. Feeling tired or having little energy?

 5. Poor appetite or overeating?
 6. Feeling bad about yourself—or that you are a
    failure or have let yourself or your family down?
 7. Trouble concentrating on things, such as reading
    the newspaper or watching television?
 8. Moving or speaking so slowly that other people
   could have noticed? Or the opposite—being so
   fidgety or restless that you have been moving
   around a lot more than usual?
 9. Thought that you would be better off dead or
    hurting yourself in some way?**

                                                                         SEVERITY SCORE TOTAL ____________

                                               (FUNCTION)
10. If you are experiencing any of the problems on this form, how difficult have these problems made it for
you to do your work, take care of things at home, or get along with other people?
            (0)                           (1)                              (2)                           (3)
       Not difficult at all          Somewhat difficult               Very Difficult            Extremely difficult

                                                                                 FUNCTION LEVEL ____________
                       Scoring the Patient Health Questionnaire

I. Severity score
 Assign a score to each response by the number value under the answer headings (Not at all = 0;
   Several Days = 1; More than half the days = 2; and Nearly every day = 3).
 Total the values for each response to obtain the severity score.

II. Severity scores to diagnose depression and determine clinically significant depression (CSD)
 Determination of clinically significant depression (CSD) and ‘other’ depressive syndromes
     Severity scores of 10 or higher on the PHQ have 88% sensitivity and 88% specificity for the
        diagnosis of major depression. When a PHQ score of 10 or greater is obtained, the clinician should
        interview the patient and review the PHQ responses to confirm the presence and clinical validity
        of significant depressive symptoms. Most (but not all) patients with PHQ scores of 10 or greater
        will meet rigorous criteria for a DSM-IV diagnosis of major depression. From an operational point
        of view, all patients with a PHQ score of 10 or greater AND any diagnosis of depression will be
        classified as having CSD (“clinically significant depression”).
     Patients with PHQ scores of 5-9, may have another depression diagnosis (dysthmic disorder,
        adjustment disorder with depressed mood, depression NOS, etc).
         To meet criteria for a dysthymic disorder, a patient must have experienced a depressed mood
            and some other depressive symptoms for ‘more days than not’ over the previous two years,
            along with some functional impairment from the depressive condition
         To meet criteria for a minor depression (e.g. adjustment disorder with depressed mood,
            depression NOS, etc), the patient should have a PHQ score of 5-9 and experience some
            functional impairment from the depressive condition
         If patients previously met criteria for major depression (or CSD) and have improved so they
            now have the lower PHQ scores, they should generally be diagnosed with major depression in
            partial remission.
 Use the following grid to guide your interpretation of depression severity

       0–4                Not clinically depressed
       5–9                Mild Depression
       10 – 14            Moderate Depression
       15 or greater      Severe Depression

   Use the following metric to assess depression outcomes.
     A 5-point decrease in PHQ score is considered a “clinically significant improvement (CSI)”
     A 50% decrease in score is considered a “response”
     A PHQ score<5 is considered “remission”

IV. Use of the PHQ to make a more rigorous diagnosis of major depression (optional)
The scoring system described below presents the more formal, originally validated diagnostic scoring
system for the PHQ. Mastery of this scoring system may be useful for clinicians who are interested in
mastering the most rigorous use of the PHQ to diagnose major depression, but is not necessary for
participation in the collaborative and is not necessary for the provision of evidence-based care for
depressed patients.
    To make the diagnosis of major depression, count the number of depressive symtoms according to the
    following system:
     For questions 1-8, count the number of symptoms the patient checked as “More than half the
        days” or “Nearly every day”.
     For question 9, count the question positive if the patient checks “Several days,” “More than half
        the days, or “Nearly every day.”
     Use the following interpretation grid to diagnose depression sub-types:

       0 – 2 PHQ symptoms            Not clinically depressed
       3 – 4 PHQ symptoms*           Other Depressive Syndrome**
       5 or more PHQ symptoms* Major Depression
      * PHQ items #1 or #2 must be one of the symptoms checked.
      ** See algorithm, Treatment Guideline for Other Depressive Syndromes, to differentiate minor vs.
      chronic depression, with treatment recommendations (Resource Section, page 38)